Original title: Emerging indications, in-hospital and long-term outcome of balloon aortic valvuloplasty in the transcatheter aortic valve implantation era. Reference: Francesco Saia et al. EuroIntervention 2013;8:1388-1397
Until a few years ago, aortic valvuloplasty had been abandoned by many centers due to its limited results and frequent complications. The current guidelines recommend aortic valvuloplasty to treat patients with symptomatic severe aortic stenosis as a bridge for TAVI in unstable patients or patients requiring non cardiac emergency surgery, and as palliation when there is no alternative treatment.
This cohort of consecutive patients that received aortic valvuloplasty was divided in 4 groups according to reason of indication: 1) bridge for TAVI; 2) bridge for surgical valve replacement (B-AVR); 3) cardiogenic shock and 4) palliation to relieve symptoms. All procedures were performed with the Cristal Balloon (Balt,.Montmorency, France) balloon-to-annulus ratio 1:1; inflation required a pacemaker only occasionally. The study included 415 consecutive patients with an average logistic EuroSCORE of 23.9±15.3%. When both groups were compared, the palliation group turned out to be older, with a greater prevalence of neurological function, while the shock subgroup resulted younger, with greater prevalence of previous infarction, low ejection fraction and generally presenting as acute coronary syndrome. The bridge for TAVI subgroup presented the lowest EuroSCORE and often required non cardiac emergency surgery (mostly oncological). This subgroup often presented porcelain aorta, kidney disease, obstructive chronic pulmonary disease and previous revascularization.
The mean transvalvular gradient was reduced more than 50% in 215 patients (51.8%), between 30 and 49% in 105 patients (25.3%) and more than 30% in 95 patients (22.9%). In-hospital mortality was 5.1% and mostly occurred in the cardiogenic shock subgroup (56.5% vs. 2% in other subgroups). Stroke incidence was 0.5%, vascular complications 2.2% and life threatening bleeding was 1.5%. Mortality was 33.2% at one year and 57.4% at two years, with the greatest incidence in the cardiogenic shock group and the lowest in the B AVR group. Globally, 30.8% required a new valvuloplasty within 2 years after indicative procedure.
Conclusion:
The number of aortic valvuloplasty procedures has increased mainly because of the larger number of patients with severe aortic stenosis and high surgical risk and because of the new indication of bridge for TAVI. In this population with high comorbidity rates, valvuloplasty resulted relatively safe but the long term result continues to be poor. Unless there was a clear contraindication, more effective and definite treatments such as surgical replacement or percutaneous replacement should immediately be performed.
Editorial Comment:
Post dilation severe aortic insufficiency was observed in 11 patients (2.6%), which could be corrected in 8 patients with a very interesting maneuver. According to the authors, in most cases severe insufficiency is due to an immobilized sheath in open position and this can be corrected manipulating a pigtail catheter reinforced with a stiff guide- wire inserted into the sinus of Valsalva, between the aortic wall and the blocked valve. In the TAVI era, palliation valvuloplasty may be questioned seeing that the PARTNER study has shown percutaneous replacement is superior to medical treatment and valvuloplasty, which is why all non surgical patients eligible for TAVI should pursue this treatment with no delay.
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